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Surgery & Orthopedics Patient History
Name
*
First
Last
Patient Name
*
Today's Date
*
MM slash DD slash YYYY
What symptoms have you observed at home?
*
How long have the symptoms been present?
*
Did the symptoms start suddenly?
How would you describe the symptoms?
Progressing
Staying the same
Improving
Unsure
Is your pet otherwise normal?
*
Yes
No
Are there other medical problems we need to know about?
*
Has your pet had any previous surgery other than spay or neuter?
*
Yes
No
Is your pet on any medication?
*
Yes
No
What medication(s) has your pet taken for this problem in the past?
If none, please type NONE.
If medications are being used to treat the condition for which we are evalutating your pet, have they been associated with any improvement in the condition?
Have medications been previously used that were NOT successful?
Please list ALL medications your pet currently takes for UNRELATED problems. If none, please type NONE.
*
Did you bring any radiographs or lab test results?
*
Yes
No
Did you bring any Medical Records?
*
Yes
No
What kind of food do you feed your pet?
*
How much of this kind of food do you feed your pet per day?
*
What types of snacks/treats do you feed your pet and how often?
*
Do you have other pets?
*
Yes
No
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